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Service Type: 0 Screening

(Accountable Health Care HRSN Screening Tool below)

Capped at 30 minutes for the waiver period. A second screening may be authorized following a “major life event.”

Each Medicaid Member will receive a screening annually or on an as-needed basis due to a major life event.

• Conduct HRSN assessment using the Screening Tool.
• Enter responses into SCN IT Platform.

Service Type: 1.1 Navigation

Maximum of two hours (one hour after each screening) for waiver period.

Link non-eligible Medicaid Members to local benefits and programs.

• Help members access federal, state, and local benefits.
• Work with members on eligibility and care coordination (phone, virtual, or in person).
• Document activities in the IT platform and care plan.

Service Type: 1.2 Enhanced HRSN Care Management

Maximum of five hours through waiver period

Link eligible Members to Enhanced HRSN Services

• Assess eligibility, manage referrals, and coordinate care.
• Arrange transportation and educate members about services.
• Follow up to ensure services meet members' needs.
• Document all actions in the IT platform and care plan.

2.1 – 2.2c capped overall at $10,000 for cost of work. No reimbursement for “Social Care Navigator” or other staff coordinating the work.

2.1 Home Accessibility and Safety Modifications

Limited adaptations to allow the Member to live independently. Services include general education on how to use and properly care for equipment.

2.2a Home Remediation Service: Mold and Pest Remediation

Services may include mold and pest remediation.

2.2b Home Remediation Service: Ventilation Improving Systems

Repairs or improvement of ventilation systems.

2.2c Home Remediation: Equipment Provision

Medically necessary mini refrigeration units as needed for medical treatment and prevention (e.g., insulin)

The services below refer to 2.2a – 2.2c

• The Social Care Navigator refers the member to a “dwelling assessment provider” to evaluate the home for necessary changes.
• The dwelling assessment provider creates a plan, called a Scope of Work (SOW).
• The Social Care Navigator reviews the SOW, approves the needed services, and sends it to a service provider, making sure it stays within the budget limits.
• If the project costs more than $2,000, the provider must get at least three bids to ensure fair pricing.
• After bids are finalized, the provider or subcontractor starts the approved modifications.

2.3a Asthma Remediation: Self-Management Education

Maximum four hours in-person, two hours virtual for waiver period

Health education to expand asthma knowledge.

• Follow national asthma guidelines and focus on working together for asthma care.
• Services must be provided by qualified professionals.
• At least two in-person visits (one at the start and one at the end) must be done at the recipient’s home.

2.3b Asthma Remediation and Supportive Products

Cost-based, up to cap of $8,000

Services to remove indoor allergens and supply products to reduce asthma triggers. Asthma remediation contractors must hold appropriate licenses.

• The Social Care Navigator refers members to an Asthma Remediation Provider to assess their home for changes needed to reduce asthma triggers and improve indoor air quality.
• The provider creates a Scope of Work (SOW) with recommended services, costs, and administrative fees.
• The Social Care Navigator reviews the SOW, approves services, and refers it for execution, ensuring it stays within budget limits.
• For projects over $2,000, at least three bids must be collected, and the lowest qualified bid selected.

2.4 Medical Respite

Per diem: $245 - $388 up to 90 days per year

Temporary residential care for unstably housed Members who do not need to be hospitalized but require health care services.

• Short-term pre-procedure care and post hospitalization care by NYS-certified Medical Respite Programs.
• Must also offer transitional supports to secure stable housing and Enhanced HRSN services prior to the Member’s discharge.

2.5 Rent / Temporary Housing

Per unit per month, limited to 6 months (rates vary per region)

Rent / Temporary Housing includes payment for rent and/or short-term, temporary stays for up to six months.

• Services should be delivered by contracted experienced community-based providers and are registered as a 501(c)(3) or 501(c)(4) non-profit organization
• Contracted rent / temporary housing services may be performed by for-profit organizations at the SCN Lead Entity’s discretion.

2.6a Utility Setup - Activation Expenses

Cost-based, up to cap, one time, up to $350

Assistance with setting up utility services in Member’s new community living setting.

• Utility costs are limited to households receiving rent assistance / temporary housing

2.6b Utility Setup – Back Payment

Up to capped amount, one time: $4,566

Covers costs of back payments to secure and maintain utility service.

• Utility costs are limited to households receiving rent assistance / temporary housing

2.6c Utility Assistance

Cost-based, up to cap per month $761

Expenses for the following types of utility payments: gas/oil, electric, water, sewage, garbage, internet and phone (inclusive of landline and cell phone)

• Utility costs are limited to households receiving rent assistance / temporary housing

2.7 Pre-tenancy Services

Maximum 6 hours through waiver period

Assist with searching for rentals and contacting apartments, application process, negotiating lease agreements, and preparing for and attending tenant interviews.

• Services should be delivered by contracted experienced community-based providers and are registered as a 501(c)(3) or 501(c)(4) non-profit organization
• Contracted rent / temporary housing services may be performed by for-profit organizations at the SCN Lead Entity’s discretion.

2.8a Community Transitional Supports (CTS)

Cost-based, up to capped amount. (rates vary per region)

Assistance with the set-up of the new housing unit to ensure that it meets the Member’s needs.

• Included supports: deposit, utility activation fees, movers, and relocation expenses, pest eradication, pantry stocking (limited to a max of 30 days of food), household goods, and furniture.

2.8b CTS Broker's Fee

Cost-based, SCN-level cap.

2.9 Tenancy Sustaining Services

Maximum six hours through waiver period

Providing tenant rights education and eviction prevention services.

• Linking to free or affordable legal services.
• Assist in establishing a bank account and paying bills.
• Assistance in securing entitlements.
• Understanding and meeting the obligations of tenancy.
• Address behaviors that may jeopardize housing.
• Help resolve disputes with landlords and/or neighbors.
• Assist with housing recertification processes.

2.10 Housing Transition and Navigation Services

Maximum of four hours through waiver period

Services to assist with an eligible Member's transition into a new home, including:

• Assist with the set-up of the new housing
• Connect Member to resources aiding with housing costs and other expenses;
• Review the living environment and collaborate with the relevant provider staff where the individual is institutionalized to ensure a seamless transition to the community.

3.1 Nutrition Counseling and Education

Maximum of at two hours through waiver period

• Nutrition counseling and education services, covering topics on healthy meal preparation and connecting Members with grocery budget resources
• Services must be provided by certified dietitians, nutritionists, or nurse dieticians.
• Providers should be knowledgeable about nutrition principles and methods to help members achieve food security and meet dietary needs.
• Providers must follow best practices for food safety and assess nutrition needs based on age, activity, and health conditions like diabetes or obesity.
• Assessments guide food planning, tailored counseling, and meal preparation advice.
• Counseling and education can be for individuals or groups, covering nutrition assessments, meal planning, and grocery shopping guidance

3.2 Medically Tailored or Clinically Appropriate Home Delivered Meals

$10 - $16 per meal, up to 6 months (or 11 months for high-risk pregnant / post-partum individuals). Possibility of re-authorization.

Meal plans tailored to the medical needs of the Member, approved by a Registered Dietitian Nutritionist (RDN) or Certified Dietitian Nutritionist (CDN). Meals must adhere to established nutrition guidelines.

• Service is limited to 3 meals per day and can only be delivered to a Member's home.

3.3 Medically Tailored or Nutritionally Appropriate Food Prescriptions

$97 - $146 per week, up to 6 months (or 11 months for high-risk pregnant / post-partum individuals). Possibility of re-authorization

Food prescriptions in the form of a nutrition voucher or food boxes.

• Vouchers and coupons may only be redeemed at food pharmacies, farmer's markets, mobile markets, and Community Supported Agriculture (CSA) subscriptions.
• Vouchers will have a stated dollar amount and will serve to provide 3 meals/day, 7 days/week.

3.4 Fresh Produce and Non-perishable Groceries

$30 - $78 per week, up to 6 months (or 11 months for high-risk pregnant / post-partum individuals). Possibility of re-authorization

Pantry stocking of fresh produce and nonperishable groceries (excludes meat and dairy products). Fresh Produce and non-perishable groceries will serve as a nutritional supplement for up to 3 meals/day, 7 days/week.

3.5 Cooking Supplies: Kitchenware, Microwave, and Refrigerator

Global capped amount for each SCN (varies by region).

Cooking supplies that are necessary for meal preparation and nutritional welfare for a Member when not available through other programs, including microwave and refrigerator

• Should be provided by a CBO.
• Social Care Navigators to determine the specific needs of each Member
• Cooking supplies may include pots and pans, chef's knife, mixing bowls, cooking utensils, cutting board, eating utensils, plates, bowls, glassware, silverware, can opener and colander.
• The cost of a microwave and refrigerator can also be covered.

4.1 Transportation

Up to 6 months, with global capped amount for each SCN (varies by region).

Transportation services to Enhanced HRSN Services and activities. Transportation services may include taxi/livery, rideshare, or public transportation

Examples of eligible services or activities, include but not limited to:

• Housing appointments;
• Housing court (eviction prevention);
• Local Department of Motor Vehicles appointments;
• Employment interviews;
• Education and support for chronic conditions;
• Court, probation, parole, and order of protection-related appointments;
• Childcare / Parenting classes; and
• Food pharmacies, farmer's markets, mobile markets.

The Social Care Navigator will determine the most cost-effective and appropriate mode of transportation.